Canadian Gene Cure Foundation
Foundation Canadienne Géne Cure 

First Name:

Last Name:

Mailing Address:

City:

Province:

Postal Code:

Telephone:   Please use the following format: (123) 456-7890

Birth date: January February March April May June July August September October November December  /  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  1997 1996 1995 1994 1993 Students must be born before December 31, 1997 to be eligible to apply.

Email Address:

Gender: Male Female

Your Current Grade:

*For Sciences please indicate physics, chemistry or biology and the final grade
**Please mark NC (not completed) for any courses you are currently taking or have not taken at all

Please select one of the following:
I prefer to be placed in a wet lab

I prefer to be placed in a computational lab, learning how computers are used to manage and process large sets of biological information

Either

As some of our labs are in Quebec, please indicate here if you are fluent in both English and French
Yes, I am fluent in both English and French

School Name:

Mailing Address:

City:

Province:

Postal Code:

Telephone:   Please use the following format: (123) 456-7890

What is the full name of your science teacher who will be sending your letter of reference?

First Name:

Last Name:

Email Address:

Telephone:

Spring Break 2014 Start Date:   Start date is the first Monday

Spring Break 2014 End Date:   End date is the last Friday

All information in your application is confidential and will be used solely for selection purposes by CGCF selection committee.

How did you first learn about the Gene Researcher for a Week program?

Through a teacher

Through a friend

Through a family member

Other website, please specify:

Please paste your essay below. Essays should be 300-500 words.

2 + 7: